ORIGINAL ARTICLE

Shoulder & Elbow

2016, Vol. 8(2) 124–129
! The Author(s) 2016
Do changes in hand grip strength Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
correlate with shoulder rotator DOI: 10.1177/1758573215626103
sel.sagepub.com
cuff function?

Ian Horsley, Lee Herrington, Rebecca Hoyle,

Evie Prescott and Nathan Bellamy

Abstract
Background: Shoulder pain as a result of rotator cuff pathology is one of the most common musculoskeletal complaints
presenting within primary care. Assessment of hand grip strength has been proposed as an indicator of rotator cuff
function. This experimental study assessed the relationship between grip strength and shoulder lateral rotator muscle
strength in a number of different shoulder positions, aiming to investigate whether such a relationship existed and
whether grip strength could be used as a functional assessment tool for the posterior cuff.
Methods: Twenty-seven healthy, physically active, volunteers (19 males, eight females) with no history of shoulder, upper
limb or neck injury comprised the study group. The mean (SD) age was 19.8 (5.7) years (range 18 years to 23 years). Grip
strength (measured with hand grip dynamometer) and lateral rotator strength (measured with a hand held dynamom-
eter) was measured at neutral, 90 abduction, and 90 abduction with 90 external rotation.
Results: The correlation between grip strength and shoulder lateral rotation strength ranged between r ¼ 0.91
(r2 ¼ 0.84) and r ¼ 0.72 (r2 ¼ 0.52) across all positions.
Conclusions: A strong correlation between grip strength and lateral rotator strength was shown at all positions for
both left and right hands, suggesting that assessment of grip strength could be used as a rotator cuff monitor of
recruitment function.

Keywords
hand grip, lateral rotator strength, rotator cuff, shoulder
Date received: 3rd July 2015; accepted: 11th December 2015

decrease in the sub-acromial space during elevation,

Introduction
The overall prevalence of shoulder pain in the UK
population is estimated to be around 7%,1 with shoul-
der impingement syndrome (SIS) being the most com-
monly diagnosed shoulder disorder in the primary
care.2,3 In 1972, Neer4 coined the term sub-acromial
impingement and proposed a pathomechanical model
in which mechanical compression of the soft tissues
within the sub-acromial space occurred as a conse-
quence of narrowing of the sub-acromial dimensions.5
During active elevation, the humeral head superiorly
migrates 1 mm to 3 mm over the initial 30 to 60 6
before stabilizing in the centre of the glenoid, although
rotator cuff weakness can lead to excessive superior
translation of the humeral head leading to a further
thus causing mechanical compression of the sub-
acromial structures.7 Repetitive micro-trauma to the
articular side of the rotator cuff can cause the tendon
to become compressed between the superior posterior
glenoid rim and the humeral head.8 This impingement
typically occurs in the presence of increased capsular
laxity or instability of the glenohumeral joint.9
Sports City, Manchester, UK
Corresponding author:
Ian Horsley, Sports City, Manchester M11 3FF, UK.
Tel: þ44 (0)7774854019.
Email: ian.horsley@eis2win.co.uk
 Horsley et al.
Improvement in strength of the shoulder muscles is
generally required during the rehabilitation process fol-
lowing shoulder injury,10 and several studies report the
presence of weakness or sub-optimal recruitment of the
rotator cuff in patients presenting with sub-acromial
impingement.11,12 In addition, the existence of an
imbalance between the agonist and antagonist muscle
groups has been shown to be one of the major risk
factors for developing shoulder injuries,13 with a reduc-
tion in the external rotator strength conceivably caus-
ing in injury.14 As a result, improvements in strength of
the shoulder muscles are generally required during the
rehabilitation process following shoulder injury.10 One
recent study15 examined the reliability of using a hand
held dynamometer, which is a more objective measure
of assessing strength than manual muscle testing,
aiming to measure glenohumeral rotation strength in
different patients and different shoulder positions, and
reported good to excellent reliability regardless of
patient or shoulder position.
Measurement of grip strength is commonly used
within rehabilitation to compare against normative
values, or to compare strength between dominant and
nondominant limbs. Alizadehkhaiyat et al.16 found that
a standardized hand grip task in a neutral position
activated supraspinatus and infraspinatus. Grip
strength has been shown to be correlated with the
strength of the upper extremity, general strength of
the body17 and as an objective measure of upper
extremity function.18 Nascimento et al.19 and
Manadlidis and O’Brien10 found a statistically signifi-
cant and positive relationship between isometric hand
grip strength and isokinetic peak torque and work
measures of the shoulder stabilizing muscles. The rela-
tionship has been proposed as a result of the require-
ment of a stable proximal shoulder girdle to enable
optimal recruitment of the distal muscles, and the
force transmitted along the myofascial pathways.20
Hand grip dynamometers have been shown to be
accurate and reliable for measuring grip strength,21,22
and easy to use. Nascimento et al.19 and Manadlidis
and O’Brien10 found a statistically significant and posi-
tive relationship between isometric hand grip strength
and isokinetic peak torque and work measures of the
shoulder stabilizing muscles.
Grip strength can be measured quantitatively using a
hand dynamometer and has been shown to provide an
objective index of the functional integrity of the upper
extremity. Hand grip dynamometry is comparatively
inexpensive, compared to conventional isokinetic dyna-
mometers, and correlation between the two has been
reported as being moderate.10
Shoulder injuries are prevalent in sport23–25 and are
multifactorial. One of the proposed mechanisms for
shoulder injury is a result of rotator cuff fatigue,
125
which contributes to superior humeral head migration
during arm elevation and causes impingement of the
soft tissues in the sub acromial space during training
activity. The present study aimed to assess the relation-
ship between grip strength and shoulder lateral rotator
muscle strength in a number of different shoulder pos-
itions. If an association was found then grip strength
measurements could be utilized within a rehabilitation
and training session to monitor rotator cuff function
with the possibility of reducing shoulder injury.
Materials and methods
Participants
Twenty-seven subjects volunteered to participate in the
study (19 males and eight females). All were healthy
and physically active, with no history of shoulder,
upper limb or neck injury. The mean (SD) age was
19.8 (5.7) years (range 18 years to 23 years). All subjects
were right-hand dominant as defined by the hand that
they wrote with. All participants gave informed written
consent and the study was approved by the University
research ethics governance committee.
Protocol
Assessment of grip strength. Grip strength was measured
using a handheld dynamometer (Takei Physical Fitness
test Grip-A; Grip Strength Dynamometer TKK Grip-
A; Cranlea & Company, Birmingham, UK).
Participants completed 5-second maximal contractions
with the arm in three different positions: neutral
(Figure 1), 90 abduction (Figure 2), and 90 abduction
with 90 external rotation (Figure 3). The wrist was
kept in neutral and the elbow at 90 flexion in all pos-
itions. Participants were standing with their feet
approximately shoulder width apart, with a wall
behind them to add stability, prevent trunk rotation
and help maintain arm position. Both hands were
Figure 1. Grip strength measurement in neutral.
126 Shoulder & Elbow 8(2)

Figure 2. Grip strength measurement at 90 . Figure 4. Lateral rotation strength measurement in neutral.

Figure 3. Grip strength measurement at 90 abduction and 90 Figure 5. Lateral rotation strength measurement at 90
external rotation. abduction.

tested three times in each arm position and verbal

encouragement was used to ensure maximal contrac-
tions. An average was then taken of these three
scores. There was a rest time of 1 minute to ensure
sufficient recovery inbetween each contraction. Block
order was used to determine the order of positions
tested to prevent any learning effect occurring and
arms were tested alternately. The tester remained the
same during all data collection. The same method was
implemented in testing rotator cuff strength.

Assessment of shoulder lateral rotator muscle strength.

Lateral rotator muscle strength was measured using a
handheld dynamometer (Hoggan MicroFET2;
Scientific LLC, Salt Lake City, UT, USA) in the same
three arm positions as those used for grip testing
(Figures 4–6) when standing. In the neutral and 90
abduction with 90 external rotation positions, the
dynamometer was placed against a wall for stability
and to give resistance to counter the maximal contrac-
tion. In the 90 abduction position, a strap was
adjusted to participants’ shoulder height and used as
an aid to the examiner to place the dynamometer
inside and resist the maximal contraction that was in
an upward direction. Both shoulders were tested three
Figure 6. Lateral rotation measurement at 90 abduction and
90 external rotation.
times in each position and verbal encouragement was
used to ensure maximal contractions before an average
was taken. A rest time of 1 minute inbetween each con-
traction ensured sufficient recovery.
Statistical analysis
The relationship between grip strength and shoulder
lateral rotator strength for each position was assessed
using Pearson’s product moment correlation.
 Horsley et al. 127

39.00 Table 1. Correlation between lateral rotator muscle strength

38.00
37.00 and grip strength at different shoulder positions.
36.00
Grip Strength 35.00
(Kg) 34.00 Correlation Correlation
33.00
32.00 left hand right hand
31.00
30.00
LeRight LeRight LeRight Neutral shoulder rotation 0.91 (r2 ¼ 0.84) 0.86 (r2 ¼ 0.66)
Neutral 90 deg 90 deg
abducted Abducted & 90 shoulder abduction 0.82 (r2 ¼ 0.67) 0.72 (r2 ¼ 0.52)
External
Rotated 90 shoulder abduction 0.78 (r2 ¼ 0.61) 0.75 (r2 ¼ 0.57)
& external rotation
Figure 7. Mean (SD) grip strength across the three testing
positions.

15.00
14.00 data of grip strength values between the sexes show
13.00
12.00 that males have higher peak strength. The peak
11.00
Lateral 10.00 strength occurs in the fourth decade in both sexes and
Rotaon 9.00
strength (kg) 8.00
undergoes a similar gradual decline.28
7.00
6.00 Several studies have shown a positive correlation
5.00
4.00 between hand gripping activity and rotator cuff
3.00
LeRight LeRight LeRight
muscle activity in line with the findings of the present
study.29–31 Kwasniewski32 compared bilateral rotator
Neutral 90 deg abducted 90 deg Abducted
& External cuff strength in patients with a unilateral hand or
Rotated wrist disorder using a hand held dynamometer and
reported a statistically significant decrease in elevated
Figure 8. Mean (SD) shoulder lateral rotation strength across
the three testing positions. external rotation strength. Kwasniewski32 stated that it
was unclear whether there is a causal relationship.
Similarly, Budoff33 found an increased prevalence of
rotator cuff weakness of the limb with an associated
Results
hand or wrist disorder.
Figure 7 shows the average grip strength for partici- Alterations in muscle activity patterns have been
pants across the three positions. Figure 8 shows the documented in the presence of shoulder dysfunc-
average shoulder lateral rotator muscle strength for tion34–36 with the activity of some shoulder muscles
participants across the three positions. The correlation increasing, whereas others decrease when gripping is
between grip strength and shoulder lateral rotation added to shoulder movements.30,37 Alterations in
strength in the neutral position was r ¼ 0.91 (r2 ¼ 0.84) muscle activity where there is pain is considered to
for the left and r ¼ 0.86 (r2 ¼ 0.66) for the right. The reduce load within the painful region to protect
correlation between grip strength and shoulder lateral from further pain and/or injury38 and gripping may
rotation strength in the 90 shoulder abducted position result in a redistribution of force in the rotator cuff
was r ¼ 0.82 (r2 ¼ 0.67) for the left and r ¼ 0.72 muscles.37 Because co-activation of the proximal and
(r2 ¼ 0.52) for the right. The correlation between grip distal arm muscles has been shown to occur during
strength and shoulder lateral rotation strength in the gripping (possibly as a result of the grip motor control
shoulder 90 abducted externally rotated position was command eliciting activity in the proximal shoulder
r ¼ 0.78 (r2 ¼ 0.61) for the left and r ¼ 0.75 (r2 ¼ 0.57) muscles),39 it is feasible that assessment of grip will
for the right (Table 1). give an indication of the activity of the rotator cuff.
This is especially likely in the light of the findings of
Antony and Keir37 who noted that infraspinatus activ-
Discussion ity increased when gripping was added to shoulder
The present study, in line with previous studies, shows motion.
that hand grip strength is most reliably assessed when The strong positive correlation found between the
standardized methods and calibrated equipment are two variables in the present study in both hands is in
utilized, even when different examiners and equipment agreement with the findings of Mandalidis and
are used.26,27 Previous studies26 found that the mean of O’Brien10 who investigated the relationship between
three grip strength trials is a more accurate measure isometric grip strength and isokinetic strength of the
than one trial of the best of three trials. Published shoulder stabilizers. This concurs with the concept of
128
shoulder stabilizer activity increasing during handgrip
actions shown in previous studies.30,37 Sporrong et al.30
found that the electromyographic activity of rotator
cuff musculature (most significantly the supraspinatus)
increased significantly during isometric handgrip tasks,
particularly in positions of shoulder flexion/abduction,
and that biceps brachii activity also increased during
handgrip. It has been suggested that this may cause
changes in activity of the shoulder muscles and poten-
tially changes in ‘internal loading’ of the shoulder.37 In
addition, Walaa and Walaa40 also found that hand grip
strength correlated with body position. They compared
hand grip strength in several positions and found that
hand grip strength decreased in the order: standing,
sitting, supine, side lying and prone. They proposed
that rehabilitation of the shoulder musculature should
be started from the prone position, followed by the
sitting or standing position after gaining more strength
in hand grip and from side-lying, sitting or standing for
shoulder abductors.40
Previous studies have shown males to have a signifi-
cantly stronger grip,41,42 although the present study
does not take sex differences into account and it may
be the case that sex has a specific effect on the relation-
ship found.
The present study has a significant limitation in that
the investigations were conducted on healthy asymp-
tomatic shoulders; it remains to be confirmed whether
a similar relationship exists in pathological shoulders.
Conclusions
Hand grip strength can be quantified by measuring the
amount of static force that the hand can squeeze
around a dynamometer43 and provides an objective
index of the functional integrity of the upper extrem-
ity.44 The results of the present study show that grip
strength can be reliably used to assess the function of
the lateral rotators of the shoulder in normal individ-
uals. We propose that this could be useful as a moni-
toring tool for assessing readiness to perform a sporting
activity and for assessment of fatigue during training. It
may also prove a useful tool when contraction of the
rotator cuff is restricted as a result of surgery and in the
monitoring of muscle atrophy.
These results show a strong correlation between grip
strength and lateral rotator strength at all positions for
both left and right hands, which suggests that assess-
ment of grip strength could be used to monitor the
function of the posterior cuff, once baseline readings
have been attained during training and rehabilitation.
With the arm in a neutral position, grip strength could
be used to monitor the stages of the rehabilitation pro-
cess, especially in patients who have a limited range of
motion and/or pain.
Shoulder & Elbow 8(2)
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Ethical review and patient consent
All participants gave informed written consent and the study
was approved by the University research ethics governance
committee.
References
1. Urwin M, Symmons D, Allison T, et al. Estimating the
burden of musculoskeletal disorders in the community:
the comparative prevalence of symptoms at different ana-
tomical sites, and the relation to social deprivation. Ann
Rheum Dis 1998; 57: 649–55.
2. de Witte P, Nagels J, van Arkel ER, et al. Study protocol
subacromial impingement syndrome: the identification of
pathophysiologic mechanisms (SISTIM). BMC
Musculoskelet Disord 2011; 12: 282.
3. Seitz AL, McClure PW, Finucane S, Boardman NB and
Michener LA. Mechanisms of rotator cuff tendinopathy:
intrinsic, extrinsic, or both? Clin Biomech 2011; 26: 1–12.
4. Neer CS II. Anterior acromioplasty for the chronic
impingement syndrome in the shoulder: a preliminary
report. J Bone Joint Surg Am 1972; 54: 41–50.
5. Neer CS II and Welsh RP. The shoulder in sports. Orthop
Clin North Am 1977; 8: 583–91.
6. Ludewig PM and Cook TM. Translations of the humerus
in persons with shoulder impingement symptoms.
J Orthop Sports Phys Ther 2002; 32: 248–59.
7. Reddy AS, Mohr KJ, Pink MM and Jobe FW.
Electromyographic analysis of the deltoid and rotator
cuff muscles in persons with subacromial impingement.
J Shoulder Elbow Surg 2000; 9: 519–23.
8. Ellenbecker TS and Cools A. Rehabilitation of shoulder
impingement syndrome and rotator cuff injuries: an evi-
dence-based review. Br J Sports Med 2010; 44: 319–27.
9. Brukner P and Khan K. Clinical sports medicine. Sydney:
McGraw-Hill Professional, 2010.
10. Mandalidis D and O’Brien M. Relationship between
hand-grip isometric strength and isokinetic moment
data of the shoulder stabilisers. J Bodyw Move Ther
2010; 14: 19–26.
11. Brox JI, Gjengedal E, Uppheim G, et al. Arthroscopic
surgery versus supervised exercises in patients with rota-
tor cuff disease (stage II impingement syndrome): a pro-
spective, randomised, controlled study in 125 patients
with a 2K year follow-up. J Shoulder Elbow Surg 1999;
8: 102–11.
12. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J and
Kennedy R. Patterns of flexibility, laxity, and strength
in normal shoulders and shoulders with instability and
impingement. Am J Sports Med 1990; 18: 366–75.
 Horsley et al.
13. Luttgens K, Deutsch H and Hamilton N. Kinesiology:
scientific basis of human motion, 8th edition. Madison,
WI: Brown and Benchmark, 1992.
14. Donatelli R, Ellenbecker TS, Ekedahl SR, Wilkes JS,
Kocher K and Adam J. Assessment of shoulder strength
in professional baseball pitchers. J Orthop Sports Phys
Ther 2000; 30: 544–51.
15. Cools AM, De Wilde L, Van Tongel A and Cambier D.
Measuring shoulder external and internal rotation
strength with a hand-held dynamometer, and range of
motion using a goniometer and a digital inclinometer:
comprehensive intra- and inter rater reliability study of
several testing protocols. Br J Sports Med 2014; 48:
580–81.
16. Alizadehkhaiyat O, Fisher AC, Kemp GJ, Vishwanathan
K and Frostick SP. Shoulder muscle activation and fati-
gue during a controlled forceful hand grip task.
J Electromyogr Kinesiol 2011; 21: 478–82.
17. Rantanen T, Era P and Heikkinen E. Maximal isometric
strength and mobility among 75-year-old men and
women. Age Ageing 1994; 23: 132–7.
18. Balogun J, Akomalafe CT and Amusa LO. Grip strength:
effect of testing posture and elbow position. Arch Phys
Med Rehab 1991; 72: 280–3.
19. Nascimento LR, Polese JC, Faria CD and Teixeira-
Salmela LF. Isometric hand grip strength correlated
with isokinetic data of the shoulder stabilizers in individ-
uals with chronic stroke. J Bodyw Mov Ther 2012; 16:
275–80.
20. Huijing PA and Baan GC. Myofascial force transmission:
muscle relative position and length determine agonist and
synergist muscle force. J Appl Physiol 2003; 94: 1092–107.
21. Mathiowetz V, Weber K, Volland G and Kashman N.
Reliability and validity of hand strength evaluation.
J Hand Surg 1984; 9: 222–6.
22. Mathiowetz V, Kashman N, Volland G, Weber K, Dowe
M and Rogers S. Grip and pinch strength: normative
data for adults. Arch Phys Med Rehabil 1985; 66: 69–74.
23. Mycklebust G, Haslan L, Barr R and Steffan K. High
prevalence of shoulder pain among elite Norwegian
female handball players. Scand J Med Sci Sports 2013;
23: 288–94.
24. Usman J and McIntosh AS. Upper limb injury in rugby
union football: results of a cohort study. Br J Sports Med
2013; 47: 374–9.
25. Abrams GD, Renstrom PA and Safran MR.
Epidemiology of musculoskeletal injury in the tennis
player. Br J Sports Med 2012; 46: 492–8.
26. Mathiowetz V. Comparison of Rolyan and Jamar dyna-
mometers for measuring grip strength. Occup Ther Int
2002; 9: 201–9.
27. Schmidt N, van der Windt D, Assendelft W, et al.
Interobserver reproducibility of the assessment of severity
of complaints, grip strength, and pressure pain threshold
in patients with lateral epicondylitis. Arch Phys Med
Rehabil 2002; 83: 1145–50.
129
28. Bohannon RW, Peolsson A, Massy-Westropp N,
Desrosiers J and Bear-Lehman J. Reference values for
adult grip strength measured with a Jamar dynamometer:
a descriptive meta-analysis. Physiotherapy 2006; 92: 11–5.
29. Sporrong H, Palmerud G and Herberts P. Hand group
increases shoulder muscle activity. An EMG analysis
with static hand contractions in 9 subjects. Acta Orthop
Scand 1996; 67: 485–90.
30. Sporrong H, Palmerud G and Herberts P. Influences of
handgrip on shoulder muscle activity. Eur J Appl Physiol
1995; 71: 485–92.
31. Sporrong H and Styf J. The effects of isokinetic muscle
activity on pressure in the supraspinatus muscle and
shoulder torque. Orthop Res 1999; 17: 546–53.
32. Kwasniewski CT. The prevalence of rotator cuff weak-
ness in patients with injured hands. J Hand Ther 2005; 18:
387–8.
33. Budoff JE. The prevalence of rotator cuff weakness in
patients with injured hands. J Hand Surg 2004; 29:
1154–9.
34. Jaggi A and Lambert S. Rehabilitation for shoulder
instability. Br J Sports Med 2009; 44: 333–40.
35. Clisby EF, Bitter NL, Sandow MJ, et al. Relative contri-
butions of the infraspinatus and deltoid during external
rotation in patients with symptomatic subacromial
impingement. J Shoulder Elbow Surg 2008; 17(1 Suppl):
87S–92S.
36. Labriola JE, Lee TQ, Debski RE and McMahon PJ.
Stability and instability of the glenohumeral joint: the
role of shoulder muscles. J Shoulder Elbow Surg 2005;
14: 32–8.
37. Antony NT and Keir PJ. Effects of posture, movement
and hand load on shoulder muscle activity. J Electormyog
Kinesiol 2009; 17: 578–86.
38. Hodges PW and Tucker K. Moving differently in pain: a
new theory to explain the adaptation to pain. Pain 2011;
152: S90–8.
39. Hodder JN and Keir PJ. Targeted gripping reduces
shoulder muscle activity and variability. J Electromyogr
Kinesiol 2012; 22: 186–90.
40. Walaa MES and Walaa SM. Influence of different testing
postures on hand grip strength. Eur Sci J 2014; 36:
290–301.
41. Parvatikar VB and Mukkannavar PB. Comparative
study of grip strength in different positions of shoulder
and elbow with wrist in neutral and extension positions.
J Exerc Sci Physiother 2009; 5: 67–75.
42. Puh U. Age-related and sex-related differences in hand
and pinch grip strength in adults. Int J Rehabil Res 2010;
33: 4–11.
43. Massy-Westropp NM, Gill TK, Taylor AW, Bohannon
RW and Hill CL. Hand Grip Strength: age and gender
stratified normative data in a population-based study.
BMC Res Notes 2011; 4: 127–31.
44. Myers DB, Grennan DM and Palmer DG. Hand grip
function in patients with rheumatoid arthritis. Arch
Phys Med Rehabil 1980; 61: 369–72.